When Times Get Tough: Regional Economic Conditions and Preventable Hospitalizations Among Older Patients with Diabetes

In times of economic uncertainty and decline, we all take steps to be more frugal. Clipping coupons, spending less on entertainment and dining, or swapping out a favorite brand name good for a generic alternative won’t hurt you. But sometimes the lengths one can go to save money will.

When sick, some forego the doctor’s visit in favor of a cheap(er) over-the-counter remedy. Others ration an expensive prescription like insulin to make the supply last.

Deferring health care comes with a cost though – often to those who are already vulnerable. For younger and healthy adults, putting off an overdue medical appointment might not be all that risky. But for those who are older or who struggle with chronic disease, deferring care raises the risk that an otherwise preventable illness or complication will become serious.

Our health and health care are not immune to economic changes, but there has been limited study as to how shifting economic tides impact quality of care.

Recent Study

In a study published in Medical Care, evaluators from the Partnered Evidence-based Policy Resource Center explored the relationships between regional economic conditions and quality of care by examining the risk of preventable hospitalization or death among older Veterans with diabetes who seek care from Veterans Health Administration (VHA).

The authors followed a cohort of over 468,000 VHA patients aged 65 years and older with a diabetes diagnosis from July 1, 2012 to June 30, 2014. Baseline data were captured for one year prior to diabetes diagnosis, and Veterans in the cohort were followed for at least 24 months.

Using The Agency for Healthcare Research and Quality Prevention Quality Indicators, the researchers identified four outcomes of interest. These included three types of preventable hospitalization associated with diabetes (short-term complications admissions, long-term complications admissions, and uncontrolled diabetes admissions) and death.

The authors identified six market variables that characterized health insurance coverage and affluence at the regional level. Health insurance variables included the percentage of VHA enrollees aged 65 years and older, Medicare Advantage market penetration rate, and percentage of health insurance coverage among males aged 18-64 years. Regional affluence variables included median household income, Housing Pricing Index, and Veteran unemployment rate.

The evaluators employed a 2-stage discrete-time Cox proportional hazards model to assess the relationships between quality of care in VHA primary care services and economic conditions.


The study found that most regional market variables were associated with preventable hospitalization or death. Higher rates of health insurance coverage were associated with lower utilization of VHA care and a lower risk of preventable hospitalization or death. Similarly, higher median household income and higher Housing Pricing Index were associated with lower risk of preventable hospitalization and death. However, the authors didn’t find any effect from Veteran unemployment rate.

Using survival analyses, the authors predicted that increases in VHA’s primary care staffing levels could reduce the risk of preventable hospitalization or death for the average Veteran with diabetes at the average VHA facility. But any beneficial reduction could be partially offset if the VHA facility was also affected by the economic downturn.


The authors acknowledged several limitations. As a VHA-specific analysis, the findings might not be generalizable to all patients or health systems. As an observational study, there may be unobserved confounding effects impacting the validity of the findings. The evaluators also found it challenging to use administrative data to identify diabetes diagnoses because of differences in how diagnoses were documented and coded in the electronic health record.

The study’s findings support the need for a better understanding of how health systems, especially safety-net providers, can build resilience to withstand challenging economic conditions. The authors suggested that VHA could benefit from being attuned to changes in regional economic conditions and allocating national resources accordingly. They argued that non-VHA safety-net hospitals, especially those reimbursed with value-based payment models, may be unfairly penalized for lower quality of care resulting from worsening economic conditions, ultimately exacerbating quality concerns.

Quality health care may be most important when times get tough – for that reason, health systems should leverage every available tool to ensure that those most affected by economic downturns receive the highest quality of care possible.

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